Clinicopathological features and outcome of esophageal neuroendocrine tumor: A retrospective multicenter survey by the digestive endoscopy society of Taiwan.

BACKGROUND & AIMS: Esophageal neuroendocrine tumors (NET) are very rare and mostly carcinomic, carrying poor prognosis. There is still no guideline or consensus on the treatment for esophageal NET. METHODS: Patients with histologically-proven esophageal neuroendocrine tumor were recruited from 9 hospitals in Taiwan between 2002 and 2017. Clinical, laboratory, radiological, endoscopic, pathological data, treatment strategies, follow-up periods, and survivals were collected retrospectively. RESULTS: In total, 39 esophageal NET were analyzed and 38 were neuroendocrine carcinoma (NEC). Sixteen (41%) patients had mixed components with either adenocarcinoma (N = 9, 23%) or squamous-cell carcinoma (SCC) (N = 7, 18%). 64.1% of the patients experienced dysphagia and ulcerative mass was the most comment endoscopic finding. There was a higher proportion of drinkers (54.1%), betel chewers (21.6%) and smokers (64.9%) among the patients than in the general population in Taiwan. Five patients (12.8%) had been diagnosed with other cancers. Definite chemoradiotherapy (N = 14, 35.9%) and surgery (N = 7, 17.9%) were the major treatment. Patients with Ki-67% above the median level (50%) in the tumors tended to have worse survival (P = 0.06). However, presence of mixed component was not a significant survival predictor in our study (P = 0.56). CONCLUSION: Mixed component of an esophageal NET is commonly observed. Staged workup and the principle of treatment can follow that for the common cancer type of esophagus. The risk factors and behaviors of esophageal NEC in Taiwan seem to be similar to that of esophageal SCC.

Circulating microRNA-22-3p Predicts the Malignant Progression of Precancerous Gastric Lesions from Intestinal Metaplasia to Early Adenocarcinoma.

BACKGROUND: Gastric cancer has a poor outcome and identifying useful biomarkers from peripheral blood or tissue could allow its early detection, or potentially precancerous changes, thus improving the curative rates. MicroRNAs (miRNAs) have been shown to offer great potential in cancer diagnosis and prediction. AIM: Here, we investigated the role of plasma miRNAs in the natural course of gastric cancer, from intestinal metaplasia to early cancer. The findings were used to understand whether patients at a high risk of malignancy could be given appropriate interventions in the early disease process, such as using endoscopic submucosal dissection to treat gastric dysplasia or early gastric cancer. METHODS: Participants were divided into healthy control, intestinal metaplasia (IM), and dysplasia/early cancer (pT1a/b) groups. Microarray was used to select potential markers in tissue. RESULTS: Quantitative real-time polymerase chain reaction data showed circulating miRNA-22-3p had significantly different expression in patients with precancerous lesions or gastric adenocarcinoma. The areas under the curve of incomplete IM versus healthy control, low-grade/high-grade dysplasia, early gastric cancer, and GED were 0.8080, 0.8040, 0.8494, and 0.8095, respectively (all P values < 0.05). CONCLUSIONS: Circulating miRNA-22-3p could be a potential biomarker for gastric precancerous dysplasia and early cancer detection.

Differentiation of the Follicular Variant of Papillary Thyroid Carcinoma From Classic Papillary Thyroid Carcinoma: An Ultrasound Analysis and Complement to Fine-Needle Aspiration Cytology.

OBJECTIVES: It is difficult to establish a diagnosis of the follicular variant of papillary thyroid carcinoma (PTC) using fine-needle aspiration cytology (FNAC). Preoperative features on ultrasound (US) imaging are different between follicular PTC and classic PTC. This study developed a risk score system to differentiate follicular PTC from classic PTC and to correlate the risk score of follicular PTC with its FNAC categories and pathologic features. METHODS: The US features, FNAC results, and pathologic reports of 156 follicular PTC nodules and 152 classic PTC nodules from 296 patients with PTC along with their clinical characteristics were reviewed retrospectively. A risk score system based on US features was developed by multivariate logistic regression to differentiate classic PTC from follicular PTC nodules. The risk scores were then correlated with the FNAC category and pathologic features of the nodules. RESULTS: The US risk score (5 × echogenicity + 3 × calcifications + 3 × marginal regularity) had an area under the receiver operating characteristic curve of 0.85 and a cutoff value of 8.0, with specificity of 87% and sensitivity of 69% for predicting a classic PTC nodule. The follicular PTC nodules with low Bethesda categorization (I-III) had a median US risk score of 6 (range, 0-11), which was higher than that of nodules with high categorization (IV-VI; median, 3; range, 0-11). CONCLUSIONS: The US risk score may be useful in differentiating classic PTC from follicular PTC and complementary to FNAC in identifying follicular PTC.

Association of endoscopic ultrasonographic parameters and gastrointestinal stromal tumors (GISTs): can endoscopic ultrasonography be used to screen gastric GISTs for potential malignancy?

BACKGROUND: Previous research shows that only 10-30% of gastrointestinal stromal tumors (GISTs) are malignant. Nonetheless, some reports suggest that all of them have some degree of potential for malignancy. Endoscopic ultrasonography (EUS) is a useful technique for differentiation of subepithelial lesions in the gastrointestinal tract. We explored EUS characteristics that might predict the malignancy potential of GISTs. METHODS: In this retrospective review of the medical records from 1999 through 2007, patients who had gastric stromal tumors diagnosed prior to surgery using EUS were enrolled. The EUS images, procedure records and tissue histopathology were reviewed. All patients were positive for C-kit. RESULTS: Of the 110 patients enrolled, 57 were males, and 53 were females. Most (67%) of the GISTs were located in the gastric body. The lesion size ranged from 6.3 to 150 mm (mean ± SD: 39.73 ± 22.49 mm). The high-risk GIST group had 19 (17.3%) patients, the intermediate-risk group had 12 (10.9%) patients and the low/very low-risk group had 79 (71.8%) patients. Thirty patients had cystic lesions (27.3%), while six patients had calcification in the lesion (5.5%). Additionally, 27 patients (24.5%) had surface ulceration visible on endoscopy. GISTs at high risk for malignancy were highly associated with lesion size (p < 0.0001), cystic change (p = 0.015) and surface ulceration (p = 0.036) but not with calcification (p = 0.667). We also found that mitosis was associated with lesion size (p < 0.0001) rather than other parameters. Age was not predictive of malignancy potential (p = 0.316). However, tumor size is the only one independent risk factor for malignancy (p ≤ 0.0001). CONCLUSIONS: The preliminary results show that large gastric GISTs with cystic change and surface ulceration may associate with a risk of malignancy, warranting more aggressive management. Nevertheless, the tumor size is more important than other factors.

Recommendations and guidelines for endoscope reprocessing: Current position statement of digestive endoscopic society of Taiwan.

Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current endoscopic reprocessing guidelines or procedures are not adequate to ensure patient-safe endoscopy. Approximately 5.4 % of the clinically used duodenoscopes remain contaminated with high-concern microorganisms. Thus, the Digestive Endoscopy Society of Taiwan (DEST) sets standards for the reprocessing of GI endoscopes and accessories in endoscopy centers. DEST organized a task force working group using the guideline-revision process. These guidelines contain principles and instructions of step-by-step for endoscope reprocessing. The updated guidelines were established after a thorough review of the existing global and local guidelines, systematic reviews, and health technology assessments of clinical effectiveness. This guideline aims to provide detailed recommendations for endoscope reprocessing to ensure adequate quality control in endoscopy centers.

Modified endoscopic submucosal dissection with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer.

BACKGROUND: Gastric subepithelial tumors are usually asymptomatic and observed incidentally during endoscopic examination. Although most of these tumors are considered benign, some have a potential for malignant transformation, particularly those originating from the muscularis propria layer. For this type of tumor, surgical resection is the standard treatment of choice. With recent advent of endoscopic resection techniques and devices, endoscopic submucosal dissection (ESD) has been considered as an alternative way of treatment. The aim of this study is to demonstrate the feasibility of a modified ESD technique with enucleation for removal of gastric subepithelial tumors originating from the muscularis propria layer, and to evaluate its efficacy and safety. METHODS: From November 2009 to May 2011, a total of 16 patients received a modified ESD with enucleation for their subepithelial tumors. All tumors were smaller than 5 cm and originated from the muscularis propria layer of the stomach, as shown by endoscopic ultrasonography (EUS). The procedure was conducted with an insulated-tip knife 2. Patient's demographics, tumor size and pathological diagnosis, procedure time, procedure-related complication, and treatment outcome were reviewed. RESULTS: Fifteen of the sixteen tumors were successful complete resection. The mean tumor size measured by EUS was 26.1 mm (range: 20-42 mm). The mean procedure time was 52 minutes (range: 30-120 minutes). Endoscopic features of the 4 tumors were pedunculated and 12 were sessile. Their immunohistochemical diagnosis was c-kit (+) stromal tumor in 14 patients and leiomyoma in 2 patients. There was no procedure-related perforation or overt bleeding. During a mean follow up duration of 14.8 months (range: 6-22 months), there was no tumor recurrence or metastasis. CONCLUSIONS: Using a modified ESD with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer and larger than 2 cm, complete resection can be successfully performed without serious complication. It is a safe and effective alternative to surgical therapy for these tumors of 2 to 5 cm in size.

Child-Pugh Score and ABCG2-rs2231142 Genotype Independently Predict Survival in Advanced Hepatoma Patients Treated with Sorafenib.

Patients with advanced hepatocellular carcinoma (HCC) are treated by immunotherapy and/or targeted agents, such as sorafenib. Several single nucleotide polymorphisms (SNPs) and clinical scores have been proposed as prognostic markers in HCC patients treated with sorafenib. This study aimed to validate the prognostic values of these markers in a tertiary referral medical center. Two independent cohorts (cohort-1 [n = 97] and cohort-2 [n = 60]) of advanced HCC patients treated with sorafenib monotherapy were enrolled. Univariate followed by multivariate Cox proportional hazard analysis identified Child−Pugh (CP) score (p < 0.001) and renal insufficiency during treatment (p < 0.001) as independent predictors in cohort-1 patients. The same analytic method revealed ascites (p = 0.000), CP score (p = 0.001), infection during treatment (p < 0.001), and ATP-binding cassette subfamily G member 2 (ABCG2)-rs2231142 genotype (p = 0.003) as independent predictors in cohort-2 patients. ABCG2-rs2231142 genotype "CC" was associated with unfavorable overall survival in sorafenib-treated HCC patients. In conclusion, the CP score and ABCG2-rs2231142 genotype served as independent survival predictors for advanced HCC patients receiving sorafenib treatment.

Substance use and esophageal neuroendocrine neoplasm: A case-control study.

Esophageal neuroendocrine neoplasms (NEN) are extremely rare and little is known about their risk factors. To identify the potential risk factors, we evaluated whether the history of substance use, including alcohol, tobacco and areca nut consumption was associated with esophageal NEN. Forty-one esophageal NEN patients diagnosed between 2002 and 2019 from 17 hospital in Taiwan were enrolled as the cases. Controls were participants who received complete esophagogastroduodenoscopy in an endoscopic cohort and 123 eligible controls were matched to 41 cases (3:1) on age and gender. Alcohol drinking and cigarette smoking significantly increased the risk of esophageal NEN, with about a fourfold risk increase in alcohol drinkers as well as cigarette smokers. Moreover, use of cigarette smoking and alcohol consumption in combination demonstrated the highest risk of esophageal NEN with the risk increasing up to 20 times compared with non-users. Alcohol consumption and cigarette smoking significantly increase risk of esophageal NEN and both alcohol and cigarette users had the highest risk.

Impact of circumferential resection margin distance on locoregional recurrence and survival after chemoradiotherapy in esophageal squamous cell carcinoma.

BACKGROUND: Close circumferential resection margin (CRM) is an established predictor for locoregional recurrence (LR) in rectal cancer but remains controversial in esophageal malignancy. As yet, little is known about the significance of CRM after chemoradiotherapy (CRT), especially in squamous cell carcinoma (SCC). This study investigated the relationship between CRM distance and recurrence after neoadjuvant CRT in esophageal SCC patients. METHODS: Between 1997 and 2005, esophageal SCC patients who underwent surgery after neoadjuvant CRT and with pathology stage T3N0M0 and T3N1M0 (metastatic lymph nodes <2) were selected. CRM distance was reassessed and divided into three groups (group 1: CRM >1 mm, group 2: uninvolved CRM but <1 mm, group 3: CRM involved). RESULTS: The cohort comprised 145 male and 6 female patients with mean age of 57 years. There were 74, 51, and 26 patients in group 1, 2, and 3, respectively. With median follow-up period of 50 months, LR developed in 30.5% of patients. Both group 2 and group 3 had significantly higher LR than group 1 (37 and 42% vs. 21%, P < 0.05). Meanwhile, mean time from operation to recurrence was also significantly shorter in group 2 and group 3 than in group 1 (267 and 269 days versus 402 days, P < 0.05). Five-year disease-specific survival (DSS) was highest in group 1 (40%). Despite the similarity in LR, 5-year DSS significantly differed between group 2 and group 3 (22 vs. 7%, P < 0.05). The higher rate of distant recurrence (DR) and concomitant LR + DR in group 3 accounted for the survival difference. CONCLUSION: In ypT3 esophageal SCC patients, CRM distance provides useful information for risk stratification in cancer recurrence and survival.

The role of age in predicting the outcome of caustic ingestion in adults: a retrospective analysis.

BACKGROUND: Although the outcomes of caustic ingestion differ between children and adults, it is unclear whether such outcomes differ among adults as a function of their age. This retrospective study was performed to ascertain whether the clinical outcomes of caustic ingestion differ significantly between elderly and non-elderly adults. METHODS: Medical records of patients hospitalized for caustic ingestion between June 1999 and July 2009 were reviewed retrospectively. Three hundred eighty nine patients between the ages of 17 and 107 years were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Mucosal damage was graded using esophagogastroduodenoscopy (EGD). Parameters examined in this study included gender, intent of ingestion, substance ingested, systemic and gastrointestinal complications, psychological and systemic comorbidities, severity of mucosal injury, and time to expiration. RESULTS: The incidence of psychological comorbidities was higher for the non-elderly group. By contrast, the incidence of systemic comorbidities, the grade of severity of mucosal damage, and the incidence of systemic complications were higher for the elderly group. The percentages of ICU admissions and deaths in the ICU were higher and the cumulative survival rate was lower for the elderly group. Elderly subjects, those with systemic complications had the greatest mortality risk due to caustic ingestion. CONCLUSIONS: Caustic ingestion by subjects ≥65 years of age is associated with poorer clinical outcomes as compared to subjects < 65 years of age; elderly subjects with systemic complications have the poorest clinical outcomes. The severity of gastrointestinal tract injury appears to have no impact on the survival of elderly subjects.

Endoscopic metal stents for the palliation of malignant upper gastroduodenal obstruction.

BACKGROUND/AIMS: Gastric outlet obstruction (GOO) is frequently caused by tumor. Recently, endoscopic implantation of self-expanding metallic stents (SEMS) has been introduced as an improved palliative treatment for GOO. This study aims to study the effect of SEMS placement on nutrient intake in patients with GOO and correlate different SEMS positions with postoperative clinical outcomes. METHODOLOGY: Fifty six non-operable patients with GOO were enrolled. Obstruction of the duodenum (n=23) or gastric outlet (n=33) were commonly found. Either Wallstent Enteral Stents, WallFlex Enteral Duodenal or partially covered Ultraflex esophageal stents were placed under endoscopic and fluoroscopic guidance. The Gastric Outlet Obstruction Score (GOOSS) was used as the main outcome measurement. RESULTS: The procedure was technically feasible in 100% of patients and gave satisfactory clinical results in 98.2% (55/56). The patients had a median survival time of 97.5 days (range 9-380). Median stent patency was 72 days with a range of 8 to 267 days. The average GOOSS, measuring oral intake, was significantly improved, regardless of obstruction site (p<0.05). We also found that the site of SEMS placement did not affect the clinical outcome. CONCLUSIONS: Palliation with SEMS is a safe and effective method for restoring gastric intake in patients with malignant GOO.

Direct peroral cholangioscopy and pancreatoscopy for diagnosis of a pancreatobiliary fistula caused by an intraductal papillary mucinous neoplasm of the pancreas: a case report.

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra-slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69-year-old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra-slim videoendoscope (GIF-N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra-slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.

Association between Hepatitis C Virus Infection and Esophageal Cancer: An Asian Nationwide Population-Based Cohort Study.

Background: Hepatitis C virus (HCV) infection causes many extrahepatic cancers, and whether HCV infection is associated with esophageal cancer development remains inconclusive. Methods: A nationwide population-based cohort study of the Taiwan National Health Insurance Research Database (TNHIRD) was conducted. Results: From 2003 to 2012, of 11,895,993 patients, three 1:1:1 propensity score-matched cohorts, including HCV-treated (interferon-based therapy ≧6 months, n = 9047), HCV-untreated (n = 9047), and HCV-uninfected cohorts (n = 9047), were enrolled. The HCV-untreated cohort had the highest 9-year cumulative incidence of esophageal cancer among the three cohorts (0.174%; 95% confidence interval (CI): 0.068-0.395) (p = 0.0292). However, no difference in cumulative incidences was identified between the HCV-treated (0.019%; 0.002-0.109%) and HCV-uninfected cohorts (0.035%; 0.007-0.133%) (p = 0.5964). The multivariate analysis showed that HCV positivity (hazard ratio (HR): 5.1, 95% CI HR: 1.39-18.51) and male sex (HR: 8.897; 95% CI HR: 1.194-66.323) were independently associated with the development of esophageal cancer. Of the three cohorts, the HCV-untreated cohort had the highest cumulative incidence of overall mortality at 9 years (21.459%, 95% CI: 18.599-24.460) (p < 0.0001), and the HCV-treated (12.422%, 95% CI: 8.653-16.905%) and HCV-uninfected cohorts (5.545%, 95% CI: 4.225-7.108%) yielded indifferent cumulative mortality incidences (p = 0.1234). Conclusions: Although HCV positivity and male sex were independent factors associated with esophageal cancer development, whether HCV infection is the true culprit or a bystander for developing esophageal cancer remains to be further investigated. Interferon-based anti-HCV therapy might attenuate esophageal risk and decrease overall mortality in HCV-infected patients.

Surgical outcome of Mirizzi syndrome: Value of endoscopic retrograde cholangiopancreatography and laparoscopic procedures.

BACKGROUND: Laparoscopic cholecystectomy (LC) with associated procedures and endoscopic retrograde cholangiopancreatography (ERCP) have been the standard treatments for both common and rare biliary diseases. Mirizzi syndrome (MS) is a rare and complex biliary condition. We report our experience with MS treatment and investigate the value of laparoscopic procedures and ERCP in patient management. METHODS: From 2004 to 2017, 100 consecutive patients with MS were diagnosed by ERCP and underwent surgery in a referral center. Sixty patients were treated with intended LC, and 40 patients were treated with open cholecystectomy (OC). The clinical manifestations, ERCP and associated procedures, surgical procedures, and postoperative outcomes were investigated. RESULTS: The surgical mortality rate was 1%, while the surgical morbidity rate was 15%. The patients treated with intended LC suffered from less morbidity (5%). The percentage of postoperative residual biliary stones was 32% (n = 32), and only three patients underwent re-operation (laparotomy) for stone removal. The laparotomy conversion rate in the intended LC group was 16.7% (10/60). The length of hospitalization for the patients with successful LC was significantly shorter than that for the patients with conversion and intended OC. Csendes classification was a risk factor for conversion from LC to OC (type I vs types II to V, P < .0001). CONCLUSIONS: A combination of a laparoscopic procedure and ERCP may provide therapeutic benefits for patients with MS.

Predictors of rebleeding and mortality in patients with high-risk bleeding peptic ulcers.

BACKGROUND AND AIM: Patients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality. METHODS: A prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes. RESULTS: Bleeding recurred in 46 patients (11.8%) within 3 days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3 days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level<10 g/dl (OR 3.3) and ulcer>or=2 cm (OR 2.0). In-hospital bleeding was the only independent risk factor for mortality (OR 8.3). CONCLUSION: The study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.

Endoscopic ultrasound-guided tru-cut biopsy for diagnosis of gastrointestinal stromal tumors.

BACKGROUND/AIMS: The most common mesenchymal tumors of gastrointestinal tract are gastrointestinal stromal tumors (GIST). These tumors originate from muscularis propria layer. Tissue diagnosis is usually difficult by endoscopic mucosal biopsy. The aim of this study is to evaluate the utility of endoscopic ultrasound-guided Tru-Cut biopsy (EUS-TCB) for GISTs before treatment. METHODOLOGY: A total of six patients in the period between June 2006 and May 2009 were included in this study. EUS-TCB was performed with a 19-gauge core needle to obtain sufficient specimen for pathological and immunohistochemical studies. All tumor sizes were larger than 2 cm. Specimen size and the number of needle passes were both recorded. RESULTS: Core tissues were successfully procured by EUS-TCB in all tumors (100%). The mean tumor size was 50 mm (range 30-75 mm). The final pathological diagnosis was c-kit positive stromal tumor in five patients and leiomyoma in one patient. The mean size of specimen was 8 mm (range 3-13 mm) and the mean number of needle passes was 2 (range 1-3). No patient developed complications after the procedure. CONCLUSION: EUS-TCB is a safe, quicker procedure that offers sufficient tissue acquisition for pathological diagnosis and clinical decision-making in patients with GISTs.

Endoscopic diagnosis of Helicobacter pylori infection by rapid urease test in bleeding peptic ulcers: a prospective case-control study.

GOAL: To assess the efficacy of rapid urease test (RUT) in patients with bleeding ulcers, as well as the effects of visible blood in the stomach and short-term (<24 h) use of standard-dose proton pump inhibitor (PPI) on RUT sensitivity. BACKGROUND: The sensitivity of RUT in the diagnosis of Helicobacter pylori in upper gastrointestinal bleeding has been reported with conflicting results. STUDY: This was a prospective case-control study evaluating 324 consecutive patients with bleeding peptic ulcers (study group) and 164 with uncomplicated ulcers (control group). The presence of H. pylori infection was determined by both RUT and histology. Prevalence of H. pylori infection and the RUT sensitivity in diagnosing the bacteria between study and control groups were conducted. RESULTS: The prevalence of H. pylori infection in those with bleeding ulcers was significantly lower than that of controls (53.7% vs. 65.2%, P=0.015). The false-negative rate of RUT in the study group was significantly greater than that of the control group (16.7% vs. 5.6%, P=0.006), whereas the sensitivity rates in the study group with or without gastric blood were significantly lower than those of the controls (79.6% vs. 94.4%, P=0.005; 84.8% vs. 94.4%, P=0.019). There was no significant difference in RUT sensitivity between study group with or without visible gastric blood (P=0.41). The RUT sensitivity rate was also not significantly different between those treated with PPI and those without in patients with bleeding ulcers (82.7% vs. 85.7%, P=0.67). CONCLUSIONS: This study shows that the sensitivity of RUT in patients with bleeding ulcers is reduced. The presence of blood in the stomach and the short-term use of standard-dose PPI do not affect the RUT sensitivity in bleeding ulcers.

Caustic ingestion in adults: the role of endoscopic classification in predicting outcome.

BACKGROUND: The ingestion of caustic substances induces an extensive spectrum of injuries to the aerodigestive tract which include extensive necrosis and perforation of the esophagus and stomach. The gold standard of safely assessing depth, extent of injury, and appropriate therapeutic regimen is esophagogastroduodenoscopy (EGD). The objective of this study was to report our clinical experience and to evaluate the role of a 6-point EGD classification system of injury in predicting outcomes in adult patients diagnosed with caustic agent ingestion. METHODS: The study was a retrospective medical chart review from 273 patients admitted to the Chang Gung Memorial Hospital in Tao-Yuan, Taiwan between June 1999 and July 2006 for treatment of caustic ingestion. The patients underwent EGD within 24 hours of admission and mucosal damage was graded using Zagar's modified endoscopic classification scheme. After treatment, patients were followed in the outpatient clinic for a minimum of 6 months. RESULTS: A total of 273 patients were included for analysis. Grade 3b injury was the most common caustic injury (n = 82, 30.03%), followed by grade 2b injuries (n = 62, 22.71%). Stricture was the most common complication (n = 66, 24.18%), followed by aspiration pneumonia (n = 31, 11.36%), and respiratory failure (n = 21, 7.69%). Compared to grade 3a mucosal injury, grade 3b mucosal injuries were at greater risk of prolonged hospital stay (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.80), ICU admission (OR: 10.82; 95% CI: 2.05-200.39), and gastrointestinal (OR: 4.15; 95% CI: 1.55-13.29) and systemic complications (OR: 4.07; 95% CI: 1.81-14.07). CONCLUSION: In patients with caustic ingestion, EGD should be performed within 12 to 24 hours and categorized according to a 6-point scale. Patients with grade 3b burns identified on endoscopy have high rates of morbidity. The 6-point scale is useful for predicting immediate and long-term complications, and guiding appropriate therapy.

Outcomes of bleeding peptic ulcers: a prospective study.

BACKGROUND AND AIM: Bleeding peptic ulcers can be due to Helicobacter pylori (H. pylori) infection, use of non-steroidal anti-inflammatory drugs (NSAIDs), or idiopathic causes. The aim of this prospective study was to identify the clinical outcomes of bleeding peptic ulcers related to different causes. METHODS: A total of 390 patients with bleeding ulcers were evaluated consecutively between June 2005 and August 2006. The diagnosis of H. pylori infection was made at index endoscopy, using histology and the rapid urease test. If both endoscopic diagnostic tests were not performed, a serological test was applied to detect the presence of H. pylori infection in a previously untreated patient. The prevalence and outcome of bleeding ulcers are related to H. pylori infection, NSAID use, and non-H. pylori idiopathic causes. The outcome between patients who were admitted for ulcer bleeding (outpatient bleeder) and those who bled while hospitalized (in-hospital bleeder) was also compared. RESULTS: NSAID ulcers were noted in 223 patients, H. pylori ulcers in 102, and non-H. pylori idiopathic ulcers in 65. In total, 298 patients had outpatient bleeders, and 92 had in-hospital bleeders. The overall 3-day rebleeding rate was 11.8% and the mortality rate was 5.4%. Eighteen of the 21 mortality cases died of their underlying comorbid illness. Patients with non-H. pylori idiopathic ulcers had a significantly higher mortality rate than NSAID and H. pylori ulcers (12.3% vs 4.5% vs 2.9%, P = 0.02). Patients with H. pylori ulcers had significantly favorable outcomes than patients with NSAID ulcers (less blood transfusion and a shorter hospital stay) and non-H. pylori idiopathic ulcers (shorter hospital stay and a lower mortality). Patients with in-hospital bleeders had an adverse outcome as compared to outpatient bleeders, including a 3-day rebleeding rate (25.0% vs 7.7%, P < 0.0001), 30-day rebleeding rate (32.6% vs 12.1%, P < 0.0001), and higher mortality rate (16.3% vs 2.0%, P < 0.0001). CONCLUSION: This study emphasizes the role of non-H. pylori idiopathic ulcers and in-hospital bleeders as the determining high-risk predictors for bleeding peptic ulcers.

Preoperative staging of cholangiocarcinoma and biliary carcinoma using 18F-fluorodeoxyglucose positron emission tomography: a meta-analysis.

This meta-analysis was performed to determine the diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) in assessing primary cholangiocarcinoma (CCA) and CCA with lymph node and distant metastasis. A literature search for studies reporting the use of 18F-FDG-PET for preoperative work-up/staging in patients with CCA was performed. Diagnostic OR (DOR) was used as an index of diagnostic performance of FDG-PET/CT in predicting primary CCA, lymph node metastases, and distant metastases. The pooled DOR was 9.34 (95% CI 4.27 to 20.42) and the area under the summary receiver operating characteristic (SROC) curve was 0.8643 (SE=0.0362), indicating overall good discriminatory test performance in predicting primary CCA. Subgroup analyses based on the primary tumor site showed better diagnostic performance for intrahepatic CCA (DOR=54.44, 95% CI 13.44 to 220.49), both intrahepatic and extrahepatic CCA (DOR=32.96, 95% CI 1.41 to 768.80) and gallbladder cancer (DOR=12.93, 95% CI 1.97 to 84.80), than for extrahepatic CCA (DOR=2.55, 95% CI 0.71 to 9.20) and hilar CCA (DOR=2.75, 95% CI 0.17 to 43.72). The pooled DOR for the prediction of lymph nodes metastases in 10 studies was 11.34 (95% CI 4.79 to 26.80), with moderate heterogeneity (Cochran Q=15.14, p=0.0872, I2=40.5%). The area under the SROC curve was 0.8584 (SE=0.0729). In conclusion, 18F-FDG-PET and PET/CT were found to be accurate in the evaluation of primary tumors, lymph node metastasis, and distant metastasis in patients with CCA.